P14.24 Are lateral cervical punctures under-utilized?

Abstract

OBJECTIVE: To investigate the safety and utility of fluoroscopy guided lateral cervical punctures in current neuro-oncologic practice. BACKGROUND: CSF examination is indicated in various neurological disorders including infection, inflammation, and malignancy. Suspicion of leptomeningeal metastases may require multiple lumbar punctures before a definitive diagnosis is reached. Despite multiple lumbar punctures, a diagnosis oftentimes remains elusive. Although the classic cisternal puncture is associated with morbid risks of medullary hemorrhage, fluoroscopy guided lateral cervical puncture has been noted to be safe alternative in obtaining CSF from a high cervical level. Evidence for the utility of cervical puncture after non-diagnostic lumbar punctures remains lacking. METHODS: Single institution retrospective review of fluoroscopy guided lateral cervical punctures performed at Memorial Sloan Kettering Cancer Center from 12/2009 to 1/2016. Results: CSF samples were obtained from 3193 patients between 12/2009 and 1/2016. Fluoroscopy guided lateral cervical puncture was used to obtain CSF from 52 of these patients. Previous lumbar puncture was non-diagnostic in 37 patients. In 15 patients, no prior lumbar puncture was done. Fluoroscopy guided lateral cervical punctures were performed for both therapeutic (n=2) and diagnostic (n=50) indications. Diagnostic lateral cervical punctures were undertaken in 50 patients to evaluate suspected leptomeningeal metastases (n=47) and CNS infection (n=3). Analysis of CSF from these cervical punctures altered clinical management in 15 patients (32%): 10 began chemotherapy, 1 received IVIG for confirmed paraneoplastic syndrome, CNS infection was ruled out in 2 patients; 2 others were treated for confirmed CNS infections. In 5 out of 37 patients with prior non-diagnostic lumbar punctures, leptomeningeal metastasis was diagnosed by subsequent cervical punctures. There were no immediate or delayed complications related to the fluoroscopy guided lateral cervical puncture procedures. Conclusions: Fluoroscopy guided lateral cervical puncture is both diagnostically and therapeutically useful in both malignant and non-malignant CNS disease. The procedure is well-tolerated and can alter clinical management. Fluoroscopy guided lateral cervical puncture should be considered in patients for whom LP is contraindicated or non-diagnostic.